 We will spend the maximum amount of time gathering your advice, input, comments, and experiences on obtaining and receiving healthcare in Vermont. We go to the next slide, please, Gretchen. This is what we're about. Act 167 passed by the legislature in 2022 requires the Green Mountain Care Board in collaboration with the Agency for Human Services to conduct a data-informed, patient-focused, community-inclusive engagement process aimed at helping Vermont's hospitals to reduce inefficiency, lower costs, or reduce the rate of cost growth, improve population health outcomes, reduce health inequities, and increase access to essential services. Green Mountain Care Board has asked Oliver Wyman, the group that and my team, to lead that effort. So what we are doing is we are conducting listening sessions to obtain the first-hand experiences of Vermont residents and citizens about navigating the healthcare system in Vermont. What went well, what didn't, why, what you would like to see more of, and what you think the healthcare system in Vermont should look like in the next five to ten years. We're doing this by conducting community meetings, both with the broader community, such as yourselves, but also with a variety of specific groups, including those who provide healthcare in Vermont, broadly stated physicians, nurses, emergency medicine technicians, advanced practice nurses, and physician assistants, nursing home people, home health folk, mental health people, and so forth. We're doing this this fall through multiple meetings, all conducted virtually like this one, to enable the maximum number of people to attend. And we will then formulate a series of options to assist the hospitals and hopefully improve healthcare. Those will be subjected to intense analysis over the winter. And following that, we'll take your comments again, relook at those analyzed options, reformulate them if necessary, and then come up to the community in person next late winter, and have a meeting with the hospital board and leadership to go through what those recommendations might be. Discuss the pros and cons, get their input, and then subsequently have an in-person community meeting. And in this part of Massachusetts, a town meeting to, again, review what the options might be and get your observations and advice. Then go back, relook at those options and prepare a final report, which would go to the Green Mountain Care Board and to the state legislature. Next slide. This is the team. My name is Bruce Hamry. I'm a physician. I've been in medicine in one way or another for a little over 50 years, both in academic medicine and group practice, and over the last 10 years as the partner and the chief medical officer for Oliver Wyman's health and life science practice. One of my colleagues in this is Ms. Elizabeth Sutherland, who is working with us in the area of health equity. Ms. Terry, I'll get to you when we're finished these slides. I want to get through them quickly so we can then get to comments. Ms. Sutherland and I have worked together for 10 years. She recently moved to a different consulting group, but she's leading the efforts in health equity and diversity. Mr. Sam Winters, our engagement manager. Dr. Chidera Cioecchi, one of our consultants. He's a neuro pharmacologist with an expertise in tobacco and alcohol dependency, and has spent the last several years with us working primarily in the area of government payers, Medicare and Medicaid. And Ms. Gretchell Gonzalez is staffing this, doing a lot of the day-to-day work, including this meeting. Next slide, please. This is what we're trying to do. I will keep this introduction and context setting as brief as possible. We do want to spend the maximum amount of time getting your experience, your opinions on what should be improved and if possible how to do that, and what the ideal health care system in Vermont should look like. At the end, we'll provide you an additional way or two to continue to inform us of your experience and wishes. Next slide. Vermont has been very successful at getting people insured. Only 3.1% of people living in Vermont were uninsured last two years ago, with cost being the reason most of those folks didn't have it. And that compares favorably to 8.6% of the US population being uninsured. However, despite that success, 40% of people in Vermont under age 65 are under insured, that is unable to afford the out-of-pocket health expenses for deductibles, co-pays, prescription drugs and over-the-counter drugs. Next slide, Gretchell. This shows the math. In 2020, the median family income in Vermont for a family of four was a little over $67,000 after deducting federal and state income tax, that family would bring home about $43,000. If you look below to the left, if the family and their employer could afford the premiums for one of the platinum plans from one of the large insurance companies in Vermont, the total premiums for that would be almost $40,000. If you look to the right, even with that premium plan that would have the lowest deductible and co-pay, the family would still be subject to almost $5,000 yearly in out-of-pocket medical costs if someone were ill. So almost $5,000 out of a take-home budget of $43,000, so clearly unaffordable and a reason that many people either delay seeking medical care or avoid it altogether. Next slide. This shows the wait times for obtaining specialty services at various hospitals in the state. The date is about 18 months old. Things have not improved, and certainly then and now we've heard stories of people waiting six, 12 months or longer to receive needed medical care. Again, not acceptable. Next slide. So here we are. This is it, and then we'll get to your comments and experiences. So a couple of quick housekeeping things. Please stay on mute when you're not speaking. Use the raise your hands feature found under reactions at the bottom of the screen. To raise your hand, we'll certainly call you in order. We will pause every few minutes to allow folks on the phone to make comments. Please feel free to include questions on the chat when we will take note of those as well. Let me note, as I should have at the start, that we are recording this session. The purpose of that is to allow us to accurately capture the comments that you make. We do have some members of the staff of the Green Mountain Care Board and the Agency for Human Services listening in. We may have some legislators in the state. If there are, I would ask that you please identify yourself and make any comments now you wish to make. Thank you. Please, Ms. Franson. Good afternoon. I'm Vivian. I'm living here in Braintree, which is about four miles from downtown Randolph and about five miles from Gifford Medical Center. I am 67 years old. My husband turned 68 next month. We both have Medicare. We both buy supplemental health insurance, and we both have our pharmacy plan. What we don't have is a primary care provider. And when we moved here to Vermont last January, I had a hunch we were going to have a hard time finding a primary care provider. But here it is in November, and I can declare that it's impossible for us to see a primary care provider because no one is taking new patients, no one. Early this year, I reached out to Gifford, and I found out very quickly that there are no openings for a new patient like me. But I was invited to go on their wait list, and I was told it would be at least one year. And so I thought, OK, I'll hang in there, right? So a couple of weeks ago, I decided to just check in with them and make sure that I was still on the list. They still had my correct phone number. They're very nice to me, but they let me know. Here's what they said. Yes, we've got you down. We aren't working from the waiting list yet. Oh, my. Oh, my is right. So I decided to probe a little deeper. And I wanted to let you know the inside scoop about Gifford. The one year wait list to see a primary care provider is optimistic thinking. I was told it's more realistic to say the wait for a primary care provider is, quote, indeterminate, an indeterminate amount of time. I was also told, quote, there's 100% certainty they won't be working from the wait list over the winter and through to the spring. So here I am. My husband and I, we need a medical home with a primary care provider sooner or not later. And I'm very concerned. My primary care, basic primary care services we're talking about. And I saw on your sheet there about specialist in 45 days or whatever it is. But we're saying a year now. And there's no guarantees on that. So the year, another year is optimistic thinking. And so what I want to believe, I look at the credentials from the people that are involved with this project. I'm really impressed with your credentials and the work experience that you have. I'm sure that you are a group of smart people. And I want to believe that you care about people like us and that you consider basic primary care services really important too. And I want to know, what can I do to help you? To help you do something about making primary care services accessible to people like me in this part of Vermont? Thank you so much. No, thank you. Very, very important and very lacking in many areas. What we're trying to do, I think one of the things you could do to help to be candid is we are desperately trying to get more people interested in providing medical care. As you're well aware, there is a desperate shortage of everything and certainly primary care people. So the short-term solutions, unfortunately, are very few. We are looking at other groups that might be helpful in providing primary care services. So these might include not only the folks we would all think about, advanced practice nurses and PAs, but in some ways, perhaps, if we can find enough of them, emergency medicine staff and some others. And I realize that none of these, perhaps, are as skilled all around as a primary care physician, although I would say I've been married for a number of years to a nurse practitioner who does a good job. So understand the issue. We are looking at what alternatives we can get, but nothing immediately on the horizon. There are programs in the state to provide tuition support and other assistance to people who want to become physicians or nurses or nurse practitioners, that sort of thing. So we're looking at those options and some others. But unfortunately, just nothing in the immediate short term. May I add one other piece of information that might be helpful for you? Please, please. When you go to Medicare.gov today, you will find there's a list of 49 primary care providers within a radius of 15 miles of my town here in Braintree, Vermont. And however, every single one of them, they're too busy taking care of patients. And you can't even get to them. You can't even call them directly. Again, they're taking care of patients. I don't know if telemedicine is an option for us. I don't know anything. But right now, we cannot get into health care. And we're fully insured. And we cannot find a primary care person who wants to take us on. And we're actually in pretty good health. We'd like to stay that way. Thank you so much. No, thank you. I understand. I would say one of the things which has come up repeatedly in conversation with the physicians and the other folk is that they spend a good part of their day arguing with insurance companies on your behalf and doing a lot of other paperwork for other groups. And so one of the things that should be able to be fixed is part of that, right? I mean, people are, I'll make up a number, spend an eight hours a day trying to take care of people and spend an hour or two or more on the telephone or filling out paperwork. If we can reduce that, then obviously they can see more folk. And that would be a much shorter term solution. So we will be working on those as well. I would just remind you, as I said, this process has a couple of months to go. And then some of those things will require potentially legislative action to implement or regulation change. So unfortunately, not a light switch, not a slam dunk, but I think there may be some short term options to, let's say, lighten the load of the people trying to provide care. Thank you very much. Thank you. Mr. Hines. Yeah, good afternoon. I'm, I am Jonathan Hines. I also live in Braintree, by the way. I haven't met my neighbors yet. But I mean, I've been here a long time, but I haven't met my new neighbors with the chansons. But anyway, my issue is this. I have no problem with my medical providers at Gifford. I have gotten very excellent care with them. I also get special care at Dartmouth-Hitchcock. My issue is also that I was summarily, I have Part D. I have Medicare Part D. I am 70. My wife is 73. And we have, she does not have, well, she just got Part D, which for some reason caused me to have been kicked off what I had in terms of insurance and on to a thing called Healthy Vermonters, which has not helped me. And I had two weeks, I did not get asked to be put on it. I was told I was now on it. I had two weeks to change over everything. And I found out that my prescriptions costs will be in the neighborhood of $505 a month on the deductible. That's the deductible. And then there'll be a gap for a while. And then I'll have to get to $7,000 before I'm on Catastrophic. And that'll probably be in November. So then I'll have a month. And it's going to be increased as of January 1. I was placed on this November 1. I just got some aspirin that the doctor prescribed, which I don't need to get a prescription for, but they prescribed it. And it's $12. Now, that's not a big deal, right? $12. But when you add in all the other meds that I have to pick, we're talking over $500 a month. I can't afford it. And so when I go to my wonderful physicians, I will find out that they will probably want a lab done. And that won't cost just a minor copay, not even 20%. It'll cost me an enormous amount of money. So I won't get the labs. I won't get the labs. I won't go for x-rays anymore. And when my physicians ask me to do any other kind of physical therapy or any other kinds of treatment, I won't do it now as a result of this because I can't afford it. So there's my situation. And anyway, the system is, in my opinion, not only, it's beyond broken. It's torn apart. I'm trying to be jury-rigged to death. And it just is not tenable for me or my wife. So I don't know what to say to you or tell you how to fix it. But I can't live like this. I can't get health care with the way it is right now. So the option is to not take my meds, which will kill me. And that's kind of a passive approach to things, which it's inevitable anyway that I die. But I mean, I prefer not to be the rea- I prefer that lack of insurance was not the reason for me to have to die. So there, thanks. Mr. Hansen, thank you for sharing that. Have you talked to the Office of the Health Care Advocate for the state? Oh, yeah. They're the ones that ended up putting me on this thing that I don't want, that I never even had for. OK. All right, thank you. Yeah. Understood. Mr. Martin, Mr. McMartin, Ms. Puglisi, let's go to you while we're waiting for Mr. McMartin. Thank you. Can you hear me? Yes, ma'am. Really upset about all this. I'm a nurse practitioner. I'm a family nurse practitioner. I'm retired. I'm 78 years old. And I've wanted to do something to be helpful with all of this. And I'm willing to help. But I did finally give up my license two years ago in my certification. So I guess I would like to figure out how the state can make use of people like me who've had a lot of experience. I've been a nurse practitioner since 1974. And I've worked all over the state and the medical centers and Vermont hospital here at Gifford. I've worked everywhere. But I haven't been made use of. And I'm willing to. But I have a great health care. And I don't even pay anything for it. I have an MVP program. I have a managed care program. And I hardly pay anything for anything. So there are options out there. So I'm just surprised that this last gentleman got into this situation that he's in. So I don't know. Well, I wonder. I mean, certainly you have a great deal of experience. And no, Vermont very well. Have you chatted with any of? I don't know if your area has a town nurse or what in some areas would be called a parish nurse or one of the community advocates. I'm sure any of those could use your help. I know I'm just thinking about the first person that talked about not having a primary at all. And it really frustrates me because I could certainly be helpful to a certain degree. I'm not licensed anymore. And I'm very active. I'm very healthy. Well, yeah, I would suspect that even though you couldn't work in a clear clinical role, that there would be other things that you could be helpful doing that would offload some of the effort from the clinical folk to do more of what they do. So there's no people for that. So that's what I'm thinking. I'm just to state. I think there are probably a few other people that are in the state that would be helpful that wouldn't mind doing some things and answering questions, triaging, those kind of things. And so I'm so I'm and I'd certainly be available to you guys in any fashion that I could be. Please thank you. No, thank you very much. And another good another very good thought. And we have spoken with a number of other retired health care professionals who are also helping in various ways to get to get health care to make it available. Mr. McMartin, are you ready? I think I am. Can you hear me? Yes, sir. I have a couple of I have a couple of questions. Who is Oliver Wyman and who do you get paid by? And explain that to me, please. Yes, sir. Good, good questions. Oliver Wyman is a large international consulting firm. We have a health and life science practice, which I'm part of. We do work with hospitals and health systems. I've worked around the country and in a few foreign countries to help people redesign their health care systems. OK, can I ask you a question? Please. What is your average hourly rate for your services? I have no idea because we price it a project. I'm sorry. Yeah, hold on. That's the same. I got to tell you. You call and you try to get like, what is this service cost? Yeah, well, you know, we don't really know. Yeah, it's we're sorry. No, it's just it's very frustrating that you can't call somebody or get in touch with some website. You know, what the hell are you guys costing? What what is this particular service going to cost me? And you cannot get any of that information. OK, it's the the contract that we have for the states posted. It's a public record. That's fine. I mean, that's fine, but I go on there and I look at that. And I'm going to see a bunch of gobbledygook about. OK, never let's let's move on from that. Hey, do you have a comment about health care in the state or something I absolutely do? Yes, I cannot get information on what certain procedures cost. You know, you call somebody and say, OK, what is that? You know, what is a MRI cost? Well, we can't tell you that. What does what do certain procedures cost? And you cannot get a straight answer on. Yeah, this is what it costs. That's true. What's that? No, true. You're the the feds are requiring hospitals to do that. The number don't yet. And I get that, but I went on to, for instance, I went on to find out what a certain procedure would cost at Dartmouth. And I looked through the whole thing and I couldn't find exactly what it was that I was being recommended to have done. OK. Well, I'm sorry, it should be simpler than that. No, I agree. And it needs to be more readily available so it's simpler to find. I mean, a rotator cuff, and this is what I'm talking about, rotator cuff surgery. What does that generally cost? Are you kidding me? You can't tell me this between 10,000 and 15,000 or is it between 15,000 and 20,000? Yeah. No, you're correct. I mean, it should be available that way. Well, it's not. I know. I know. That's one of the things that that needs to be done. And it is. Hold on. It needs to be done. Who's going to make that happen? The feds because they impose fines. Wait, hold on. Hold on. Hold on. We're in this community meeting. Yep. What the hell do you mean the feds are going to make that happen? No, it has to be local in Vermont. I agree. But it is a federal requirement that it happen. And we can, you know, we can certainly suggest. You know what, I'm sorry, I'm hearing this whole thing of, well, as the feds is local, it's don't. Okay, fine. The other thing that I want to talk about is unnecessary testing. Are you still there? Yes, sir. I'm sorry, I couldn't quite understand. Okay, so, so I have a rotator cuff. I went in, I had an MRI. Yes, sir. Yeah. So that was sent to Dartmouth. And I called them and said, okay, I want to come in and have a consult with the orthopedic surgeon. Okay, well, we have your MRI, but we need x-rays of your shoulder within 12 months. I said, hold on. You have my MRI. I had an x-ray 13 months ago. Are you telling me that's not sufficient? No, it's not. We have to have it within 12 months. Okay, so along in short, I had another x-ray done. I go to my consult. They bring up the MRI. They talk to me about what I need to do. And then say, hold on. What about my x-rays? Well, we don't need your x-rays. I said, hold on. What the hell do you mean? You don't need my x-rays. And they said, yeah, no, your MRIs tell us what we need to do. I guess what I'm saying here is, excuse me, hold on a second. I guess what I'm saying is, you're telling me that, you're telling me that some of these tell me I have to have these x-rays, which I had done. And now I go to my appointment and they say, yeah, we don't need these. And that probably cost the American taxpayers $1,000. Yes, sir. What the hell is going on? I don't know, but it shouldn't. Well, I get that, but I'm not getting any. It shouldn't, you know, it shouldn't. It's the federal government. It's whatever. You know what? I want to know what you guys are going to do for us. Well, I have to be honest. If there's something that involves an individual physician or group's practice, there's not anything that we can do. Well, hold on, hold on. When I went in for my review for my rotator cuff, you brought up the MRI and I said, hold on. No, you need to bring up the x-rays. Are you telling me that as a medical community, we can't say, you know, MRIs trump x-rays? Are you really telling me that? No, sir. What I'm saying to you is, I mean, certainly the medical society and the medical staff of that hospital would be able to oversee the physician or the physician's work as to whether it's appropriate and so forth. But as a matter of state regulation, right, to tell somebody, you know, if you tell your assistant or someone, well, in order for a person to be seen for a shoulder problem, they need this or that, that's not something a regulator can do. That's all I'm saying. Well, I understand that, but why the hell can't a regulator say that and say, you know what? No. And the other thing is, I forgot to mention this. I had x-rays last August and I went in in September. You tell me that an x-ray that's 13 months old is not as good as an x-ray that's 12 months old. Tell me how that works. I, sir, I can't accept that my orthopedist tells me the same thing when I go to see him. So it's not just your orthopedist. Well, I didn't get that, but I got to tell you. They didn't even look at my x-rays. I had to tell them to bring my x-rays up. And quite, quite frankly, that's bullshit. Yes, sir, I hear you. OK, good enough. That's all I have to say. All right, thank you very much, Ms. Hartman. Thank you. My name is Kathy Hartman. And I have lived in Randolph for 22 years. My primary care physician is Dr. Laura Barber, who is at the Chelsea Clinic. And I choose to drive from Randolph to Chelsea because she is such an outstanding doctor. And she's one of the best primary care physicians I have ever had. And she has been fired by Gifford because she does not see enough patients. And she sees every patient who walks in the door. And they get appointments within 24, 48 hours of their request for an appointment. And they say, well, you're not seeing enough patients. You're not earning your keep, so to speak, at the clinic. And there comes a time in a rural community like Chelsea that you have to pay for your doctors. The hospital, the community, somebody has to just suck it up and pay because the community needs one doctor. And she has an excellent reputation. Her patients love her. She's got an excellent, warm, welcoming staff. And we are crushed to lose her next month. And we don't know what we're going to do. And I think that is just appalling. Thank you. No, thank you. Appreciate the point. Others, other comments or experiences? Yeah, how do I get on here? Yes, sir, Mr. Mack. Yeah, I want to second that comment about Dr. Barber. That clinic was started by Dr. Martin years and years ago when the government gave him some tuition support. The governor, who was also from Chelsea. And now Gippert's taken that over some time ago. And Dr. Barber is just about the only GP in quite a ways around. I depend on her. I'm 73 if that makes any difference. And I'm really sorry to see that in a place where they're short of general practitioners, that they're letting somebody go on December 18 with a 90-day notice. And I don't know if there's anything that we've done about it, but there really should be something done about that. And that something could happen immediately or short term. I don't understand how the bean collars, as they are, can justify letting off the only GP in the immediate surrounding area in a very rural area, especially when they've taken over that clinic from someone else who kept that thing alive no matter how many people were seeing it. That's all I have to say. I'm sorry. Barber Gull, I wish they could change it. Thank you. Mr. Gardner. Hi, it's Randy Gardner from Randolph, former board member and local funeral director. And my concern is, as we talk about how to change health care, I want to support them not reducing specialist services in Randolph. Anecdotally sending people 30 or 40 miles away, they just don't get it done, particularly in the winter. Particularly the elderly just will not hit the freeway and go 30 or 40 miles. And so they defer it until spring or until they can. And then by then, we now have a price tag for that same thing that is now exacerbated and gone bad. And those special to people also back up the emergency room. I know of a lady who just recently had her life saved in the Gifford emergency room. The local OBGYN was able to get in there and do an emergency procedure, had to do it in the ER. It was so urgent to stop her from hemorrhaging to death. She would have died in her car or in the back of an ambulance trying to get to Dartmouth. So if there's, I just think you have to look really carefully at reducing, not reducing services and just trying to cherry pick what's available at Gifford. I think you need the whole thing. And I understand everybody's having problems with costs. But that's the real issue. Because if you chip all these people somewhere else, then we're going to look at increased waiting times or also employees that the local employees, Gifford's our largest employer in the town. If they, most Randall people, when they need to get something done, seem to head south to Dartmouth. So now those jobs and possibly residences are now in New Hampshire making things even worse for Vermont. It, understandably, it's a catch-22. But I'm just hoping that they don't take the simple approach of saying, well, we just need to centralize all these specialized services. I think that would be a huge mistake. No, thank you for the comment. I think really the only centralization that's possible, let's say, are for the really high-end things. And they're pretty much centralized, right, if you think about heart surgery or brain surgery. Because those are things that require expensive equipment. A lot of people who really know how to run on big teams and require a big population to serve. So, but certainly to get to an orthopedist or an anti-person and those sorts of things, they need to be much more generally available. So absolutely understand that. Yeah, and that's, they are now. I mean, that's the way it is working now. I just want to express support for Gifford that it stay that way. Right, no. The big stuff's going to Dartmouth or UVM now anyway. But we have a lot of really excellent specialists here. And like I say, being the local funeral director, I can tell you anecdotally, deferred treatment is a real problem. I hear a lot of stories about this and, you know, decentralizing and sending people long distances. I think it's just a big problem. Yeah, and as certainly a lot of people don't have cars and getting somewhere if they're trying, if they're also working is also a real problem. Exactly. Thank you. I guess a question since you know the area very well. Transportation, how is that handled for folks that live way out now in the country or don't have a car? Is that available? Transportation to Gifford or to... To Gifford, well, let's start with Gifford. I mean, just getting from the house to the nearest clinic or to Gifford. We do have, we have a local transportation system that people can call, even for specialized appointments, it's very responsive. I do not know about the other valleys like Chelsea and Rochester, for example. But the odds of them getting to Gifford are substantially higher than they would be if they were forced to go to Dartmouth. I mean, if you know anything about Vermont or New England in general, east-west is pretty, north-south is pretty easy. East-west is pretty complicated. Yeah, I live in central Massachusetts and the mountain's about 150 miles away from you. Yeah. Get up that way reasonably frequently. It's lovely country, but, and you've got worse roads than I do. Yeah. But people are very helpful around here too. There is an extensive volunteer network of people who get people to appointments and that's the advantage of a small community. So I think our transportation really, people should not be going without treatment because they can't get a ride. Right, no, understood. And also been given to understand by talking to the hospital folks that getting an ambulance to get people from Gifford to almost anywhere else is a very difficult issue as well. So thank you for those comments, Mr. Gardner. Appreciate it. Ms. Tardiff. I just had a little bit to add to your question about how transportation affects things. I and my family are patients at the Chelsea Clinic and I went to the Gifford listening conversation last month to hear what was going on as far as the community services were concerned. And one of the things that came up was that people who have trouble getting to their appointments have relied on our local transportation's volunteers which has basically evaporated over the last few years and there were actually a couple of the nurses from the Chelsea Clinic at that one saying that it was a real problem that they were having people cancel their appointments at the last moment because they couldn't get a ride and the transportation representative said we recognize this is a problem but four years ago we had 44 volunteers I believe and now we have 16 and nobody really has an answer for that but on the other hand we have people that need to get to the doctor and they can't get there and also you have the clinic having spaces set out for people and then they can't give it to someone else. It's a real problem. And if I could also say that I and my family are very concerned about continuity of care given that Dr. Laura Barber is going to be leaving. We need a primary care physician. I've spent over eight months trying to get a billing issue with Dartmouth result because by accident a referral went out under the signature of Rebecca Savage who is the PA, fine, fine provider but she can't do an acceptable referral for Blue Cross and so I went back and forth and back and forth trying to get it reprocessed. It was like $700 difference between having an MD signature and not having an MD signature on it. And we don't know what's going to happen and we have heard nothing from Gifford. Isn't there some kind of a legal requirement for talking to patients about continuity of care? Thank you. Yeah, thank you. Other experiences or comments? Yes, Ms. Davis. Yeah, sorry, I don't know where the hand is. So I've been trying to figure that out. Listen, it's so sad to listen to everybody's stories but I must say I have a very different story about Gifford and I have been absolutely pleased with my work that has been done over there. I was diagnosed with a lump in my breast and went through having found out that it was surgery or I mean cancer and went through the surgery and all that. I had complications which was amazing to me that the staff and the doctor and the whole hospital were there 24-7 for me. It was the best care I'd ever received and I must say the only hiccup I had was just finding out that my Blue Cross Blue Shield only covered my doctor that was my oncologist in one location and not on the place where she was actually loaned to which is up in Berlin. And so that was a little complicated and I found that even now the new oncologist I think that Blue Cross Blue Shield needs to get with it with as far as if a doctor is practicing at one or two facilities, they should be covered at whatever facility they are because the problem is that if it isn't taken care of then it falls on the patient. But my experience with Gifford has been phenomenal and I love it, it's 20, 25 minutes from my house, well actually 30, but it's nice to have such a wonderful facility so close and to have everybody so caring. I had a hip replacement done there two years ago and then I dealt with the surgery with the cancer this year. I just can't speak any better about the place. I think we need small hospitals like this and there are too many people that can't travel over to Dartmouth or up to Burlington or Berlin. So we need these small hospitals like Gifford and Eskatnie. And I just think that my experience was so nice. The staff treated me like family, we were all a team and they listened to me, I listened to them and it was a well-oiled machine. I can't say enough about it. So that's my experience and I do know that we have a very crazy, crazy health system in this country, but I do think that we also need to focus in on our little hospitals and our little clinics because they're really needed and we just don't wanna see what happened down south that happened here. So that's all I have to say. Thank you for doing your work and I really appreciate all of this. Well, thank you for the information. I have to find out more about the Blue Cross thing with not considering the physician. I guess it's in network if they're in a different place. Well, that's exactly it. If I had seen Carmen, who was my oncologist up in Berlin where she was actually on loan, she would have been out of network, but she was in network at Gifford. The new oncologist that came on is covered in Burlington and Berlin, but not at Gifford. And that's a Blue Cross, Blue Shield situation, I think. So anyways, I won't take up any more of your time. Thank you, I appreciate it. No, no, very helpful. Mr. Chase, have you been trying to say something? I didn't raise my hand, but I'm Derek Chase, I'm an orthopedic surgeon. Yeah, nice to see you again, Dr. Harmony. So I grew up in central Vermont. I babysat for one of the Gifford ER doctors. I attended UVM medical school. I'm a Freeman Foundation scholar and made a commitment to practice in Vermont. I was employed at Gifford for five years and I continued my privileges. I have comments as a provider that I'll address tomorrow, but as a patient, I'm also a patient there. And I have family members who are a patient there. And one of my big problems is the lack of orthopedic availability on call. We have zero orthopedic call. So hip fractures are getting transferred. People who run their hands through table saws don't have care. Kids who fall off trampolines don't have surgical care. We have four orthopedic providers on staff and the administration is not working cooperatively with us to provide this care. And so that's a big issue. I think as a critical access hospital, we need to provide critical access to common services including orthopedic care. So that's something I'd like to see done. And another big problem which a lot of people have mentioned is the lack of a provider continuity of care. And there's a lot of provider turnover, which is also a problem. And then lastly, speaking to price transparency, I think that's also very important. And CMS and Vermont Act 53 mandate that hospitals post their prices online. And Gifford is one of only two hospitals in the state that has not been compliant with that. So I think that is extremely important. Currently their charge master is dated October, 2022. So again, those are all things that I think could be approved upon from a patient standpoint. Thank you, sir. Other comments, experiences, Mr. Spahn? Hi, I'm Arnie Spahn. I live up here in a strode independent living which Gifford built six years ago. And me and my wife have been very, very happy with the lodgings here and more than happy with our care at Gifford. I wanted second Terry's comments on what goes on down at Gifford as far as the patients go. As far as the problems that we have in the state for medical care, it seems to be nationwide. It seems that there are not enough people going into medicine in any of the specialties well, especially in primary care or nursing. And I just have to assume that the reasons for that are inadequate compensation. And to a certain extent there's no place to live, to move into up here in Randolph or elsewhere in Vermont. We have a dire housing shortage. So those are some of the problems that face Gifford and the rest of the system. And I would certainly hope that the Green Mountain care board pay attention to those problems and work with other people to solve them. Thank you very much for pointing that out. Hearing the same issues around the state, very much. Thank you. Other comments? Yep, Bridget. Hi, my name is Bridget Meand-Briece. I'm a nurse practitioner in Rochester, Vermont, actually with Gifford. And I just wanted to comment and say that I think at a provider perspective, I know the provider meeting is tomorrow, but unfortunately I can't attend. One of the things that really helps patients that I work with is being able to have a community at Gifford that I can rely on and refer my patients to. If I have a patient who has a cardiac need and I can use our cardiac specialist, I know that that patient will be seen. Conversely, if I have a patient who's seen by an excellent physician at Dartmouth, they might not be able to be seen by that excellent physician at Dartmouth for a month or two, even if they have an acute issue. And so I do think that having smart specialty care is really important, particularly in our most rural communities. And Rochester is a very, very rural community where transportation really is an issue. And for a lot of my patients for economic issues, for all sorts of issues, getting to Dartmouth is really a tremendous burden. And so having robust rural healthcare systems is absolutely imperative. And I see better outcomes for my patients when I can use providers in my system. Right, thank you. Have you found or have you been able to use any of the telehealth access to get somebody on the line in less than a month? So I have reached out directly to clinics where I have patients who are established to try to get care. And particularly recently, I've had enormous challenges in terms of getting them care quickly when they need care quickly. And what have been, do you know, were the reasons for some of that? I've heard that some of the organizations don't have acute emergency visits that are even available until December. Okay, all right. And so I've been asked to manage those patients in primary care until they can be seen by specialties. They really do need to be seen by a specialty. Yes, of course. Okay, thank you. Ms. Puglisi. Hi, I guess in summary from all of this that I've heard today, we need more providers. We need providers not to be denied access to facilities. And I'm upset that for some reason, Gifford seems to be reducing its providers. So I think the Green Mountain Care Board can do something about that. And what I've also heard is people are probably underinsured or chose the wrong insurance company. And I'm seeing that we need cost. We need cost, Gifford needs to get in line with providing or having an easier access to costs. I will mention one thing. If you have insurance, then you need to talk to your insurance providers about procedures that you might need. And what your cost will be after. So that's kind of where I see what we've been hearing. And Gifford overall, people are really pretty happy with it. But I'm noticing that there's a lot of turnover there. People leaving, my primary may be leaving as well. So I'm gonna be a little upset about that. Do you know why? I think it's the same reason that the Chelsea provider is being let go. I think in our bottom line culture of medicine, we've got visits that are too short and providers can't do everything that they wanna do. And so they may be seeing fewer patients. So they may not, I'm not sure about that. But I think it's always gonna be the bottom line that hospital administrators talk about and are looking at. And so I think that's where we need to talk to the hospitals and make sure the primary people are there and make sure that people are seen in an appropriate time. And maybe there could be some other kind of, like I was talking about me and triaging people, maybe there needs to be some triage people that can answer questions that may be simple enough in terms of not needing a prescription or even an exam to make better use of time at the time that people have. Thank you. That you and I I think are getting the same notes. Okay. Mr. Ms. Kennedy, Bonnie and Neil, okay, let's go to Michael. I'm sorry, Mr. Ms. Kennedy. You can hear me now? Yes, ma'am. Okay, this is in regard to the Chelsea Health Center which has been there for probably 60 years. It was started by ex-governor Stanley Wilson. He was instrumental. He hired two UVM graduate students to start the health center. The health centers served the people of Chelsea, Tumbridge, Verschia, Washington. Since then, none of these towns have a doctor except for Chelsea. A large percentage of the residents here are elderly and depend on the health center to meet their needs. We have learned that Dr. Laura Barber has been terminated as of mid-December. It does not appear that she is going to be replaced. Not to take anything away from nurses, physician assistants, LNAs, the people of our community need local access to a doctor. They are not in a position to travel to Berry or Randolph. It'll be very different or difficult for all of us to find a doctor who will accept new patients. Those who can will most likely travel to Berry and become patients of Santa Vomont Network, no longer patients of Gifford. Dr. Barber is respected and liked by her patients. She is knowledgeable, kind, and helpful in all situations. When she was advised of her termination, she asked if there was another spot for her and was told, there is no place for you at Gifford. And here we are, no one can find a new doctor. No one can find a new doctor. She does not deserve to be treated this way and her residents are terribly upset by Gifford's treatment of her. She never hurries you out the door and she answers your questions in such a way that you feel you have been treated with concern and respect. I would like them to please reconsider this action. Thank you. Thank you for the comments. Appreciate it. Mr. Kosher, Michael. Yes, my name is Michael Kosher. I'm a patient and employee of Gifford Medical Center. Happened to work in accounting department. So with regards to the bean cutters doing the cutting the cost, that's not always the case. Our budgets are approved by Green Mountain Care Board and like every hospital in Vermont, the increases we may need aren't approved. So we have to live with what we got. So just to note on that, there's been a lot of calls about that. Secondly, as a patient, I've been very happy with the services here and I hate to see any of them go and I understand Chelsea's losing their primary care. I don't know if everyone knows the reason or I don't know the reason, but I know we are trying to provide the best quality care to all areas we service and sometimes doctors leave or there's reasons that we don't understand or know why, but we are trying to make that work. And I know my own primary care is also leaving as well. So it's not like I'm exempt from the same issues the community has, but I know also that Gifford is making all the efforts they can to find people and it's just so expensive because we're ending up having to hire contract employees that are twice or three times the cost minimum as a regular employee and that could be for physicians or nurses or whatsoever. And that adds an extraordinary cost of online. So yes, we are budget driven, but at the same time, we have to generate enough revenue to cover our costs otherwise we can't keep our doors open and that's what we're trying to do. And it's not about patient quality care because I know talking with people here, working with these people, being patient, quality is their primary goal and will continue to be their primary goal. I just wanna make sure that the services that are being offered aren't reduced by green amount of care board. And hopefully going forward, maybe the budgets can be increased a little bit because we're at the mercy of the insurance companies what we get paid. So the shorter business and all these other things, yeah, we're a critical care household, but we're still under a contract with these insurance payers and they dictate how much time we can spend for certain services in many cases. And it's not that the doctors don't wanna spend more time, it's just we're not getting paid for it and it's just really unfortunate circumstance of where we are in the healthcare. It is not a great system that we have now because as we've heard already, one person may have a great insurance plan and the other person doesn't more out-of-pocket expenses, less out-of-pocket expenses. There's no universal plan right now and it makes it hard to provide care when you have to deal with so many different insurance plans that have so many different options and still provide the same great care to the community. That's that's all I have for comments. I just appreciate your time and the feedback you're collecting and hopefully people understand it's not the being counters necessarily that are causing the problems. We're a heavily regulated industry and it's not just remountant care board. We have to answer to but Medicare, Medicaid and many other countless provide payers. So thanks again. Oh, thank you and thank you for the explanation. I appreciate it. Are there other comments, observations, experiences please? Is there anyone on the telephone who would like to make a comment? Yes, can you hear me? Yes, sir, Dr. Shays. No, this is actually Dr. Fazzone. I was formerly an anesthesiologist at Gifford. I was very happy and proud to be a member of the medical community there for a number of years. And I would say in the last five years the culture of that institution changed. I'm on that call right now, the video. That's what I think it's all about. Can you hear me? Yeah. Yes, sir. There was a little background for a minute, but go ahead. So that's probably something that can be addressed at another time, but my question, the anesthesia group there was replaced with a contracted group from North Carolina. And the billing that the anesthesia department did was assumed by that group and they took those proceeds. They also took a stipend for providing services. And I was told by Dan Bennett that that was gonna be less expensive for the hospital than continuing to pay the group of stable providers who'd been there for a number of years. I found that very hard to believe. And I also think I would want the Green Mountain Care Board to explore whether that loss of billing diminishes Gifford's ability to negotiate with insurance companies. I can only imagine it does. And also all I could see in that act, I did my residency at the University of Vermont and I very much wanted to practice in Vermont and I liked the sense of community. And that's what brought me back here. And to see a small community hospital like Gifford go to this big corporation and say provide our anesthesia services, I was very disappointed with that decision and I'm convinced it makes no economic sense. I noticed that there's currently an add out and it is for a CRNA. And the amount of money that they're offering is quite close. I believe it's actually, it's quite close to what I was earning when I worked there. And so they're billing this thing as a cost savings because they're hiring practitioners, you know, CRNAs and look, I mean, I think nurse anesthetists are wonderful. I'm not saying anything that they don't do a wonderful job. I'm just saying, I don't think there's any cost savings going on here. I think there's a lot of money that's going out. And I can also tell you that if when I first arrived at Gifford, Dr. D. Nicola was the chief medical officer and he treated the physicians with a lot of respect. And Dr. Ciccarelli was the chief of surgery. And again, I felt valued under those individuals. The individuals in those positions now, they've run out more doctors than you can imagine. And I mean, I spoke with a hospitalist at the hospital that I'm currently at. And I will tell you, I received a small award from my services at the current hospital, just from my program director. But I'm just saying, I feel very valued where I am. And at that place, it was, it had just, there's been a real deterioration. I think the leadership there has to be looked at. That's all I'm gonna say about that. And I also think this decision to bring in a corporation to run the anesthesia department should be examined as well. I mean, they decided to move to an electronic medical record. And that sounds great, right? Everybody loves, you know, a computerized system. This thing doesn't chart vitals, it doesn't. And it was brought by the company again, by this corporation. And it was just a way of extracting more money out of Gifford. We had paper records that were more than adequate. And if we were going to, you know, if the plan was to go to an electronic medical record, then it should have been done in a different manner. Because the entire anesthesia department at the time said, this thing's horrible. So anyway, I'm probably going on too much. But I would ask the Greenmonton Care Board to look at that decision closely. And I heard the way it was built in the last meeting and half the things they said just weren't so. So that's just something to look at. Thank you. Thank you, sir. I appreciate the comment. Are there other comments or experiences? Oh, yes, ma'am, Ms. Tardiff. Anne Tardiff, Anne, you have a hand up. Do you wish to speak? Okay, am I am muted now? Yes, ma'am. Okay, sorry about that. If no one else has something important, I have a couple of follow-up comments. That'd be great, thank you. I think I mentioned that I had been to a meeting with Clara Martin and Gifford and the Valley Transit last month in Chelsea. And one of the things that the Gifford representative was talking about was that they had basically spent the last year bringing up to speed a new EMR system. Now, there have been multiple EMR systems over the last few years, but this was supposed to solve all the problems. Well, my husband had an appointment on Monday and there were none of his records available. He had to tell them all of his medications, all of the background and everything like that. So the year that they spent acquiring and getting up this new EMR system does not seem to have been well spent. The other thing is I'm hearing other people saying that their PCPs may be leaving also. And people talking about a lot of turnover and the difficulty in retaining staff. And also it's really expensive to buy contract staff to cover shortages. If that's the case, why are they eliminating a stable long-term PCP from their system who wants to continue to practice in the area? Who likes practicing in a small rural area? That's all. Thank you very much. Oh, thank you. I appreciate the comment. Other comments, experiences, please? Mr. Crocher again. Hi, just to follow up on the previous caller's thing, the new EMR system we're going on here is Meditech and we just went live October 9th. So yeah, everything wasn't in, but it's not like we've been on this for a long time. We just went live. So it's going to take a few months to iron out the kinks and that's the case no matter what EMR system you go with. It's a large, complicated system, a lot of inner workings and it's going to have a lot better interfaces once it's all settled than what our old system did. So I was just to follow up on that other caller. Thank you. Thank you. Other comments, experiences? Mr. Mack. Yeah, just back to that same thing I was talking about before. What ability do you have in what you were doing here to lobby or advise or in any way twist the arms down at Gipper to revisit the Dr. Barber situation or any of the PCPs that you're losing? Well, I think in terms of the local situation with an individual, not much, right? We've been aimed at the, I don't know if they're the larger issues but let's say the overriding issues of trying to look at getting healthcare services including primary care, but the services into the community in an appropriate way in a way that keeps the hospital solvent and going and what changes in payment policy, regulation, recruitment, the things that the state, the Green Mountain Care Board have some authority or perhaps some ability to accomplish but in terms of the interior workings of a hospital and not anything that we're gonna do or be able to do. Do the administrators of that hospital, are they listening into these conversations? Are they hearing us or? No, I expect they're hearing you and I know that others have been listening in and the hospital board has also, well, I don't know about this situation but we are speaking with all the boards of each of the hospitals as well and I expect some of them would be listening into this session as well. I think the lady had a good point earlier when she said, I live in Washington so my choice is go north or go south. Yes, sir. Chelsea's seven miles from me. Barry's a little farther but they're gonna box me out at Chelsea. I'm not going to Gifford, that's too far. I go there when they send me to see a specialist or whatever but to go there for GP services, that's not gonna work. They're gonna lose the patient as they will quite a few others and that has to have some kind of financial impact on them as well. Yes, sir. Thank you. Yeah, anyway. Okay, thank you for your input, thank you. Yes, sir, thank you. Other comments, experiences? Yes, there's a comment in the chat about cost of living, inflation and housing. I mean, certainly we've been hearing in every part of the state that those are all issues and finding affordable housing for anyone, whether someone currently in the state without a home or trying to recruit as a problem. We did speak to a hospital earlier today to a group that said they had been able to recruit physicians and some nurses but that they had come into the area, spent a few months in rental housing or in a hotel and then they'd left. So again, housing as was pointed out in the chat was an issue. Any other comments, experiences to share or questions? Anyone on the telephone that would care to make comment? Oh, yes. Ms. Terry. Yeah, I just, under the final sentence on your main final slide, next steps, we will summarize the input. We have learned and used it to come up with solutions. Is there a way that we, that we're listening tonight can follow up on your results? Oh, yes. I mentioned at the start and I apologize if I wasn't clear. We will take all the information you're giving us and we've done roughly a hundred of meetings, not with large groups all, but with a number of different groups and folks around the state have another 50 to go. We'll take the comments plus information from the state data from here and there and formulate these options. They'll be analyzed over the winter. We'll relook at them based on what those effects are both on the hospital and on the health of the community. And then we're gonna come up to your area in late winter or early spring. My guess is probably March in person. And I and some folk on my team will meet with the hospital board and leadership. And then after that, we'll have a meeting in my part of Massachusetts, it's a town meeting where the community can gather, we'll present what we think the options are. We'll get your reaction, your advice, your input on that and from the hospital. And then we'll go back, relook at those options, reconfigure them perhaps. And then that will be the report that gets delivered to the Green Mountain Board, a care board and to the legislature. So there will be more phone calls. I'm sorry. How are we access that report? Well, we're gonna deliver it to the in-person and then it'll be posted on the Green Mountain website, I'm sure, that's their method for doing that. But you can continue, we'll give you in a minute a way to continue to give us your input. And then at the time we give the report, of course, there'll be public comment and other ways to affect that. Okay, thank you. Yes, ma'am. We're trying to give people a lot of opportunity to comment on this and to influence what happens. But I think the goal of it is to improve healthcare service in the community. Any other comments or questions? If not, we'll, yes ma'am, Bridget? I just have one more comment. I just wanted to reiterate that one of my observations is how important seeing an actual healthcare provider is to people. And so I've heard a couple of people make comments about telehealth, which is valuable. But one of the things that I think that is so valuable about Gifford is that we do have providers available to meet with patients. And again, in specialties and primary care, I know people have had some frustrations getting in, but when we can get people in, they really have a better outcome, just having that personal relationship with their providers. Right. No, well made, and I agree with you. But I think if we can't get somebody there in person at least being able to get their advice rapidly would be required. Thank you. Any other comments or suggestions? Okay. Gretchen, let's go to the last slide, please. So this is how you can continue to give us your experience advice and concerns. If you will go to this website, the Green Mountain Care Boards website, it's on this gmcboard.vermont.gov. Then you have a selection to make, or you can, which will get you to act 167 community meetings, or you can enter this whole thing, gmcboard.vermont.gov, backslash act-167-community-meetings. And write a comment and you can either attach your name or not. They'll be posted. We do monitor this. We collect all these comments. We take them into consideration along with the things you've said tonight and others are telling us as we try to formulate these options and possibilities. But just to remind you of the process we'll take another few months. Many of these things will require action either by the care board or by the legislature. So unfortunately, there are not any extremely short-term fixes here. So with that, are there any final comments or any public comments that anyone would care to make? Okay, well, thank you all very much. I do apologize for being late. I was having more of my technical difficulties than usual, but I apologize for that. I thank you for taking time out of your afternoon and evening and wish you all a pleasant evening. Thank you.